Provider Demographics
NPI:1306393376
Name:BLATCHER, KENTRELL (LAC)
Entity Type:Individual
Prefix:
First Name:KENTRELL
Middle Name:
Last Name:BLATCHER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 N JEFFERSON PLACE CIR APT I
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-8622
Mailing Address - Country:US
Mailing Address - Phone:504-430-8685
Mailing Address - Fax:
Practice Address - Street 1:3084 WESTFORK DR STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2254
Practice Address - Country:US
Practice Address - Phone:504-430-8685
Practice Address - Fax:225-246-8507
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5099101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3249341Medicaid